The point is not who is right and who is wrong about airborne transmission. The point is not science but safety. Scientific knowledge changes constantly. Yesterday’s scientific dogma is today’s discarded fable. When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today. We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. Until this precautionary principle is fully recognized, mandated and enforced in Ontario’s hospitals, workers will continue to be at risk.

—Justice Campbell, Chair of the SARS Commission

POSITION

New evidence and information on COVID-19 is emerging daily, and CFNU’s recommendations remain based on emerging science and Occupational Health and Safety principles, including the precautionary principle; in particular, as it applies to nurses using their professional clinical judgment1 when performing a point-of-care risk assessment2. As well, the occupational health and safety principle of the hierarchy of controls applies. It starts with eliminating the hazard when possible. When that cannot be accomplished, a combination of engineering and administrative controls, combined with personal protective equipment, must be applied. The system is called a hierarchy because you must apply each level in the order that they fall in the list; a systematic comprehensive approach must be taken to reducing hazards; a hierarchy of controls cannot be applied in a piecemeal fashion.

1 Professional judgement: knowledge, skills, reasoning and education.
2 Point-of-care risk assessment: a risk assessment undertaken by the HCW prior to any interaction with the patient to determine the risk based on, for example, the client symptoms, the specific task, or the environment and the related potential for exposure, in order to determine the appropriate personal protective equipment (PPE) to protect themselves and their patients, and prevent and control the spread of infectious viruses in acute care, long-term care and the community.

As promised, our Network of Occupational Health & Safety (OH&S) experts have reviewed and revised CFNU’s position on COVID-19 as of March 23, 2020, in light of the declaration of a pandemic by the World Health Organization and the spread of the virus throughout Canada.

It is the position of the Canadian Federation of Nurses Unions (CFNU) that, in the event of an outbreak of any new respiratory virus, we acknowledge that the best respiratory protection for health care workers at risk is a fit-tested N95 or greater respirator (e.g., powered air-purifying respirator (PAPR), given emerging science and the precautionary principle.

All nurses and frontline health care workers at risk in their area of work (based on an organizational infectious disease risk assessment) with the potential for exposure, and/or who are caring for a suspected or confirmed 2019 novel coronavirus patient, should be provided, fitted for and have access to a NIOSH-approved N95 or greater respirator (e.g., powered air-purifying respirator (PAPR)), and trained, tested and drilled to safely don and doff it by the employer.

The CFNU recognizes the critical importance of the point-of-care risk assessment (PCRA), an activity that is based on the individual nurses’ professional judgment (i.e., knowledge, skills, reasoning and education). All nurses and frontline health care workers at risk in their area of work are required to perform a point-of-care risk assessment. If a nurse feels the protective equipment they have been provided is inadequate, given the patient acuity, environment or other factors, they should be able to access a higher level of PPE.

At a minimum, as required of and by employers, all employees must also be equipped with personal protective equipment for contact and droplets precautions for suspected, presumed or confirmed cases of COVID-19, including gloves, eye protection (face shield and goggles), isolation gowns and surgical/procedural masks, for which they must also be trained and drilled in safe use.

Airborne precautions and the use of respirators N95 or higher must be mandated at all times in clinical areas considered aerosol-generating medical procedures ‘hot spots’ (e.g.: intensive care units (ICU), emergency rooms, operating rooms, post-anaesthetic care units and trauma centres) that are managing COVID-19 patients.

Point-Of-Care Risk Assessment (PCRA)

Given the amount of uncertainty around COVID-19 and the current threat to health care workers across Canada, the Canadian Federation of Nurses Unions (CFNU) recognizes the critical importance of the point-of-care risk assessment (PCRA), an activity that is based on the individual nurses’ professional judgment (i.e., knowledge, skills, reasoning and education). Underlying the PCRA is the principle that individual health care workers are best positioned to determine the appropriate personal protective equipment (PPE) required based on the situation and their interactions with an individual patient. They do so by evaluating the likelihood of exposure to themselves or others based on a specific task, environment, conditions, interaction or patient. Among the factors that should be considered in the PCRA are: the potential for contamination of skin or clothing; exposure to blood, body fluids or respiratory secretions; the potential for inhaling contaminated air; the patient’s ability or willingness to comply with infection control practices (e.g., wearing a mask); whether care requires very close contact; what engineering and administration controls are in place; and whether the patient could require an aerosol-generating medical procedure at any point and/or is in an aerosol-generating hot spot” (e.g.: intensive care units, emergency rooms, operating rooms, post-anesthetic care units and trauma centres) that are managing COVID-19 patients. Personal protective equipment should be selected based on the potential for exposure in order to minimize the risk of exposure to HCWs, a specific patient or other patients in the environment.

Screening and Triage

For those workers involved in triage and screening and testing for COVID-19, ideally a floor‑to‑ceiling plexiglas barrier with speaker phone would eliminate worker exposure to the hazard if there was no further direct contact with a patient required. However, if the barrier is not in place and direct contact is required, other administrative and engineering controls such as disposable equipment, signage procedures, training, separate examination rooms and waiting area should be in place before direct contact with the patient, and workers must be equipped with the PPE described above, trained and drilled in its use. Patients should be provided with surgical masks as a source control to be donned before entering the health care environment. Further, it is evident that for the direct care/treatment of presumed and confirmed cases, engineering controls are insufficient to prevent exposure.

Nasopharyngeal Swab

For those engaged in taking a nasopharyngeal swab for obtaining specimens for testing from patients with known or suspected cases of COVID-19: HCWs must perform a PCRA to determine the level of risk. Some factors to consider are the patient’s respiratory secretions, the frequency and severity of coughing, any breathing difficulties and whether there is a fever. If the PCRA indicates the need for respiratory protection, a fit-tested N95 respirator as a minimum must be worn.

Designation of aerosol-generating medical procedures hot spots

All workers in so-called ‘hot spots’ where there could be aerosol-generating medical procedures (AGMP) (e.g.: intensive care units, emergency rooms, operating rooms, post-anaesthetic care units, negative pressure rooms, single-patient rooms used to isolate patients in absence of negative pressure rooms, and trauma centres) that are managing COVID-19 patients should wear at least N95 respirators or greater (e.g., powered air-purifying respirator (PAPR)) at all times; head and foot protection; eye protection (e.g., face shield that covers the sides of the face); gloves; impermeable gowns, or at least fluid-resistance gowns, as they may suddenly be required to undertake an AGMP (e.g., intubation) and thus may risk exposure to the virus.

Having zones of the hospital dedicated to patients with presumed or confirmed cases of COVID-19, as is taking place in other jurisdictions, would also be useful; workers in these zones would be required to wear at least N95 respirator masks.

Precautionary Principle and OH&S Law

A recent legal opinion posted by a leading Canadian law firm Osler, Hoskins & Harcourt LLP recommends employers “benchmark to current best practices” and follow “appropriate precautionary measures”:

“Where there is conflicting evidence as to whether a certain precautionary measure is required or not, hospitals should adopt the elevated precautionary measure(s). Hospitals should be cognizant that it will be the hospital that will be legally liable for any failures to protect patients and staff from harm, even if hospitals have relied on federal, provincial or municipal government directives in establishing its own plans, policies and procedures.”

This legal opinion makes it clear that health care employers must respect nurses’ professional judgement as expressed through the PCRA to determine when and where to use PPEs and to determine under what circumstances the level of PPE needs to be increased. The CFNU is clear that the clinical judgement of our members – as expressed through the PCRA – should prevail.

Employers’ responsibilities are clearly laid out in provincial OH&S law: employers must work with joint OH&S committees on their pandemic plans, protocols and measures; provide training, testing and drilling for all employees on health and safety measures; establish a respiratory protection plan and provide fit-testing for N95 respirators to all employees who may need them as based on their areas of work or potential work responsibilities; and employers are also responsible for making PPE readily accessible and available to health care teams so they can do their jobs safely.

Several jurisdictions in Canada have established surgical masks as part of the precautions to be used with suspected and actual COVID-19 patients, when not involved in AGMPs. The CFNU rejects the ‘blanket’ rules currently in place which treat the safety of health care workers as an afterthought and fail to respect their professional judgement in undertaking a PCRA.

It is our position that a pan-Canadian approach to emergency preparedness must incorporate the precautionary principle so that all nurses and health care workers across Canada have the same access to health and safety in their workplaces, including the same standard for personal protective equipment (PPE) and pandemic planning. If the precautionary principle is not instituted throughout the health care system, which includes long-term care facilities, nurses and other health care workers could readily become vectors spreading the disease to each other and their patients and families. Further, it is crucial for effective infection control and health and safety strategies that a hierarchy of controls (engineering, administrative and at the worker level) be developed and implemented throughout the organization, in conjunction with joint health & safety committees that include direct care providers (including nurses) and their unions.

If AT ANY TIME you feel that your employer is not following the OH&S laws and principles as outlined above, please contact your union immediately.

The above position draws on international guidance on infection prevention and control in health care settings from the U.S. Centers for Disease Control and Prevention (CDC), the EU European Centre for Disease Prevention and Control (ECDC), and similar guidance in the UK and Australia. For more information, visit CFNU’s website for information on international infection control and prevention guidance, and the current science related to COVID-19, including how it spreads and the efficacy of personal protective equipment.

Nurses are expected to be prepared, 24 hours a day, to face any number of health emergencies. The ability to respond quickly and efficiently to emergencies is fundamental to the nursing profession. However, rapid response requires the support of many parts of the health care system. It requires emergency preparedness planning, proper administrative and engineering controls, the support of the administrators of the health system, as well as the government to ensure the necessary protocols, measures, procedures, training and protective equipment that take into consideration risk and the precautionary principle.

For workers, we recognize the critical importance of the point-of-care risk assessment and that individual health care workers, using their knowledge, skills, judgement and education, are best positioned to determine the appropriate PPE required based on their interaction with an individual patient in a particular environment.

Questions or concerns?

If you have any questions or concerns, please speak with your union or a member of your Joint Occupational Health & Safety committee.

Employer Checklist

Consult the Joint Occupational Health & Safety Committee on all measures, procedures and training with respect to COVID‑19.

Review and update existing institutional pandemic plans, developed in conjunction with the joint OH&S committees, to ensure they include staffing, communication, education and training for staff with respect to pandemic preparedness plans and the health risks of the current emergency and/or pandemic situation.

Ensure that workers have ready access to PPE, are regularly trained and fit-tested for the N95 respirator (at least biennially or in accordance with personnel changes) and regularly drilled in any potential hazards, including the reason for and use of protective equipment such as the N95 respirator and powered air-purifying respirator (PAPR), if available, how to don and doff all equipment, and all safety protocols.

It is essential to ensure that health care providers are fully trained, tested and drilled in the care provisions/protocols required during a pandemic, including conducting a point-of-care risk assessment before each interaction with a patient and/or the patient’s environment to evaluate the likelihood of exposure to contact, droplet and/or aerosols in care procedures, equipment and treatment settings to determine the appropriate safe work practices.

Conduct a comprehensive organizational risk assessment, including determining all points of potential entry (and how to restrict them using prominent signage and limiting access) and other points of potential exposure for workers (e.g., screening, triage, isolation rooms).

Implement changes in policies, procedures, equipment and the environment to eliminate or minimize identified risks in accordance with a hierarchy of controls approach to hazards.

Have in place relevant travel screening and worksite/unit exposure controls. Ensure that sufficient protective measures and equipment are in place for all screening locations at all entry points.

Have an adequate supply of appropriate N95 respirators, gloves, impermeable gowns or at least fluid-resistant gowns, head protection, face shield and foot protection as well as PAPR (for aerosol-generating medical procedures, e.g. intubation) and full body protection on hand.

When a suspected patient is identified, implement isolation measures in a negative pressure room for those with symptoms and move patient immediately to this room, separate from other patients, with access to a dedicated washroom or commode, and ensure that only trained and properly equipped personnel (with appropriate PPE) are assigned as care providers and to enter these rooms.

Create dedicated teams of clinicians who are protected with and trained, tested and drilled in the use of proper personal protective equipment for COVID-19, including teams trained in the use of N95 respirators and PAPR, if available (for aerosol-generating procedures), donning and doffing protocols, who can care for both suspected and confirmed cases of COVID-19.

Ensure sufficient staffing is available to supplement nurses and other health workers who need to care for patients in isolation, and schedule work in a manner that allows for multiple rest periods and recovery periods, as well as implement systems for monitoring fatigue.

Conduct a point-of-care risk assessment employing your professional judgement before each interaction with an affected patient and/or the patient’s environment to evaluate the risk of exposure to contact and/or contaminated air in care procedures, equipment and treatment settings; at any time during this risk assessment nurses may request an increase in PPE.

If you have any health conditions of concern when caring for COVID-19 presumed or confirmed cases, please consult your health care provider.

Avoid touching your eyes, nose and mouth with hands to prevent self-contamination; clean hands before contact with any part of the body.

Avoid contact between contaminated gloves/hands and equipment and the face, skin or clothing when removing PPE.

Familiarize yourself with your collective agreement and legislation with respect to pandemic preparedness, occupational health and safety (OH&S) and the right to refuse dangerous work.

STOP if you do not have the required personal protective equipment or properly fitted respiratory protection, and/or have not been trained, drilled and tested in its care, use and limitations, and speak with your manager or supervisor; document the situation and copy your union and Joint OH&S Committee representative.

REPORT any health and safety concerns, including gaps in adequate protocols and procedures and/or communications, access to PPE, fit-testing and/or training or other health and safety concerns to your manager or supervisor, copying your Joint OH&S Committee and your union.